Rapid protection of the gastroduodenal mucosa against aspirin-induced damage by rabeprazole.

BACKGROUND: The ability of a proton pump inhibitor to reduce or prevent NSAID-induced gastroduodenal damage during the first 24 h has not been tested. AIM: To determine, whether oral rabeprazole, administered 5 h before the initiation of therapeutic dosing of aspirin protects the gastroduodenal mucosa. METHODS: Normal subjects were randomized into two groups - one received rabeprazole, 20 mg at 07:00 hours and the other placebo, before initiation of aspirin 650 mg at 12:00 hours, and then q4 h for 3 days. Upper endoscopic examinations were performed on all subjects at baseline, 24 and 72 h after initiation of aspirin. Gastroduodenal mucosal damage was scored. RESULTS: Thirty subjects were compliant with study medications and underwent three endoscopic examinations. Salicylate concentrations were similar for the placebo and the rabeprazole groups at all times. On rabeprazole, the Lanza scores were significantly lower compared with placebo at 24 h (1.3 +/- 0.26 vs. 2.1 +/- 0.26, P < 0.05) and at 72 h (1.3 +/- 0.29 vs. 2.3 +/- 0.28, P < 0.05). Gastric antral erosion counts were less with rabeprazole than placebo at 24 (4.1 +/- 1.3 vs. 7.6 +/- 2.0, P > 0.05) and 72 h (5.3 +/- 1.8 vs. 8.0 +/- 1.5; P > 0.05). CONCLUSIONS: Rabeprazole, initiated 5 h before the start of therapeutic dosing with aspirin, decreased Lanza scores and antral erosion counts at 24 h. These findings suggest that prophylaxis with rabeprazole could start concurrently with aspirin administration.

Whole gut transit scintigraphy in the clinical evaluation of patients with upper and lower gastrointestinal symptoms.

OBJECTIVE: In a single noninvasive, quantitative test, whole gut transit scintigraphy (WGTS) measures gastric emptying (GE), small bowel transit (SBT), and colonic transit (CT). The aim of this study was to investigate the clinical utility of WGTS in patients with functional gastrointestinal (GI) symptoms. METHODS: A total of 108 patients with either dyspeptic upper GI symptoms (n = 35) or constipation (n = 73) underwent WGTS. Patients consumed a meal of 99 m-Tc egg sandwich with 111-In DTPA in water. They were imaged every 30 min for 6 h to measure GE and SBT, and at 24, 48, and 72 h to measure CT. RESULTS: Of 108 studies, 104 were analyzable. In patients with upper GI symptoms, 14/35 (40%) had delayed GE of solids, 4/35 (11%) delayed SBT, and 11/35 (31%) delayed CT. Of those with constipation, 13/69 (19%) had delayed GE, 5/69 (7%) delayed SBT, and 43/69 (65%) delayed CT. WGTS changed the initial clinical diagnosis in 47/104 (45%) and altered patient management in 70/104 (67%) of the patients. CONCLUSIONS: Transit abnormalities of the upper GI tract and colon are common in patients with functional GI symptoms. Patients with upper GI symptoms frequently have delayed GE, whereas those with constipation tend to have predominantly delayed CT. In many patients with functional GI symptoms, there was evidence of a diffuse GI motility disorder. Whole gut transit scintigraphy is a simple, clinically useful test, as it frequently leads to a change in diagnosis and, therefore, patient management.

Role of flexible endoscopy in the evaluation of possible esophageal trauma after penetrating injuries.

OBJECTIVE: In urban medical centers, penetrating injuries of the chest, neck, and head are frequently encountered due to the use of firearms and sharp weapons. Successful management of esophageal injury requires a high index of suspicion and prompt diagnosis. The role of flexible endoscopy, a readily available modality, has not been studied extensively in the management of potential esophageal injuries due to trauma. METHODS: A retrospective chart review of 55 patients who underwent emergent flexible endoscopy for the evaluation of suspected penetrating esophageal injuries was performed to determine if endoscopy was safe and if it yielded information that altered patient management. RESULTS: Flexible endoscopy was performed safely in all patients. It yielded a sensitivity of 100%, specificity of 92.4%, a negative predictive value of 100%, and a positive predictive value of 33.3% for detecting an esophageal injury. Although positive findings (prevalence, 3.6%) are infrequent, no esophageal injuries were missed. Endoscopy altered patient management in 38 (69.1%) patients. CONCLUSIONS: Emergent flexible endoscopic examination of the esophagus is a safe and useful diagnostic tool in the early evaluation of penetrating injuries. Flexible endoscopy resulted in four negative surgical explorations, which was deemed acceptable by the Trauma Service, as the consequences of a missed esophageal injury is likely to be devastating.

Enteroscopy improves the clinical outcome in patients with obscure gastrointestinal bleeding.

Push enteroscopy is often performed to identify and treat the source of blood loss in patients with obscure gastrointestinal blood loss. This study was designed to determine whether enteroscopy alters the clinical outcome in these patients. This was a retrospective study of 50 patients who underwent push enteroscopy for obscure GI blood loss. Information was obtained from chart review and telephone contact with both patients and physicians. Data collected included patient demographics, days hospitalized, and packed red blood cell transfusions for 6 months pre- and postprocedure, diagnostic yield, return to premorbid function, and a global patient's and referring physician's assessment of efficacy. For analysis, patients were subgrouped by whether or not enteroscopy identified a source for the bleeding. Complete data were available for 41 of 50 patients. Sixty-seven percent were female, with a mean age of 65+/-2.1 years. Positive findings were seen in 78%. In patients with a positive finding, there was a decrease in hospitalization days (from 17.4+/-4.5 to 7.2+/-3.0) and transfusions (from 7.9+/-1.3 to 3.0+/-1.1) in the 6 months following the procedure. Patients without findings had a significant decrease in transfusions (from 13.7+/-6.7 to 8.2+/-4.9), but not hospitalization. Forty-four percent of patients returned to premorbid function. One-third of patients and half of their physicians felt that the procedure was beneficial. Push enteroscopy improves patient clinical outcome in obscure GI bleeding--especially when a diagnostic finding is obtained.

Rapid progression of Barrett's esophagus to metastatic esophageal carcinoma in a patient with chronic lymphocytic leukemia.

Barrett's esophagus is a common premalignant condition that predisposes to the development of adenocarcinoma of the esophagus through a process of transformation from metaplasia to dysplasia and then carcinoma. Periodic endoscopic surveillance with multiple biopsies is adopted by most physicians to detect dysplasia or early carcinoma. We report a case of an 80-year-old white man with chronic lymphocytic leukemia (CLL) who had periodic endoscopic surveillance without any evidence of dysplasia or cancer, and who died of metastatic carcinoma of the esophagus only 18 months after his last upper endoscopic examination. We suspect that the relative immunosuppressed state resulting from his CLL was the major contributor to the rapid progression of the Barrett's esophagus to cancer. Patients with CLL have higher risk of second cancers, and several cases of aggressive carcinomas have been reported in association with CLL. This is the first case report of metastatic esophageal cancer arising in Barrett's esophagus in a patient with CLL. This case suggests that we might need a more aggressive surveillance strategy for Barrett's esophagus in patients with CLL or other immunocompromised conditions.

Effects of in vitro versus in vivo red cell labeling on image quality in gastrointestinal bleeding studies.

OBJECTIVE: Both in vivo and in vitro red cell labeling methods are available for performing gastrointestinal bleeding studies. While in vitro labeling has been shown to result in higher binding efficiency, no comparison of clinical image quality has been reported between those techniques. This study compares in vivo and in vitro methods using both subjective and objective measurements of image quality. METHODS: A consecutive series of gastrointestinal bleeding studies performed on 23 patients using in vivo labeling was compared to a series of 23 studies using in vitro labeling. Images at 30 min postinjection were randomized and analyzed by two observers. Subjective evaluation of image quality, as well as renal activity, was based on a comparison of femoral vein and inferior vena cava activity to adjacent background using numerical scores with a scale of 0-3. Image quality using the subjective scores was further classified as acceptable and poor. Target-to-background measurements of femoral vein to adjacent soft tissue in the thigh and inferior vena cava to adjacent abdominal background also were made. RESULTS: In vitro label subjective image quality was acceptable in 87% and 91% of cases for vascular and renal activity, respectively, but only 35% and 52% for in vivo labeling. In vitro label target-to-background ratios were significantly better than in vivo label for the femoral vein and inferior vena cava, as well as for the subjective assessment of vascular image quality, but not for renal activity. CONCLUSION: In vitro red cell labeling improves clinical image quality as compared with in vivo labeling. Both subjective and objective measurements of image quality are useful for comparing the results of labeling methods.

Idiopathic Constipation and Fecal Incontinence.

Patients with constipation or fecal incontinence have great potential for remediation. Both disorders warrant a thorough diagnostic evaluation to search for remediable causes, especially to identify defecation disorders. Constipation should be treated by relieving any impactions and then starting a course of fiber supplementation of at least 20 g per day. If not successful, other agents such as lactulose, polyethylene glycol solutions, or stimulants can be added. Biofeedback may be very helpful. If all else fails, several surgical procedures are available. Fecal incontinence should be treated by fiber supplements, encouragement of regularity, and enemas as needed. Kegel exercises and biofeedback are often helpful, but surgery may be needed and is most effective in recent onset or traumatically induced incontinence.

Detection and treatment of angiodysplasia.

Angiodysplasias of the colon are difficult to detect but usually easy to treat. Colonoscopy is the most sensitive and specific method for detection, but angiography, endoscopic ultrasound, and nuclear medicine techniques are also useful. Emerging optical analysis techniques, such as remote endoscopic digital spectroscopy and enhancement with opioid antagonists, may improve detection rates. Treatment is performed conventionally with contact probes. Other methods of treatment include lasers, injection therapy, angiographic techniques, rubber band ligation, hormonal therapy, and surgical resection.

Regional differences in gastric acidity and antacid distribution: is a single pH electrode sufficient?

UNLABELLED: Accurate measurement of intragastric acidity has both clinical and investigational importance in studying gastric pathophysiology. OBJECTIVES: The aims of this study were fourfold: (1) to investigate whether regional differences in intragastric acidity exist; (2) to determine intragastric acidity after a standard antacid was administered in both the fasting and fed states; (3) to monitor gastric emptying of and anatomic distribution of radiolabeled antacid during fasting and postprandial periods; and (4) to determine whether the regional effects of ingested antacid correlated with the anatomic distribution of the antacid. METHODS: Eight normal male volunteers were studied after fluoroscopically guided nasogastric placement of a tube assembly containing four pH electrodes, with one electrode in each quartile of the stomach. Simultaneous pH readings were made from the four electrodes while fasting, after administration of fasting antacid (30 ml, 79 mEq buffering capacity), postprandially, and after postprandial antacid ingestion. All subjects repeated the protocol on a separate day, five of them using radiolabeled antacid. Gastric emptying and gastric distribution over time of radiolabeled antacid were determined for comparison to regional intragastric acidity. RESULTS: Intragastric acidity varied regionally over time in response to meals and to fasting and postprandial antacid. In the fasting state, intragastric acidity returned to baseline after antacid ingestion in a proximal to distal (cardia to antrum) sequence, while postprandial antacid resulted in a return to baseline acidity in a distal to proximal (antrum to cardia) sequence. Radiolabeled antacid distribution paralleled intragastric pH and hydrogen ion concentration in the fasting state, with 82% of the antacid localizing in the distal half of the stomach within the first minute after antacid ingestion. Postprandially, the greatest initial and most prolonged antacid buffering effect occurred proximally, correlating with the presence of radiolabeled antacid. Postprandial antacid remained in the stomach for a longer time (T1/2 = 93.1 +/- 23.4 min) compared with fasting antacid (T1/2 = 23.6 +/- 11.1 min). CONCLUSIONS: Measurement of acidity in the four quartiles of the stomach demonstrated regional variation in response to both food and a standard antacid. A single pH electrode does not detect regional intragastric pH differences.

Nonexpandable silicone esophageal stents for treatment of malignant tracheoesophageal fistulas: complications and radiographic appearances.

BACKGROUND: The aim was to evaluate the radiologic appearances and complications that occurred after placement of nonexpandable silicone stents used as palliative therapy for patients with malignant tracheoesophageal fistulas (TEFs). METHODS: Records of 11 patients (6 males, 5 females) who underwent placement of esophageal stents for malignant TEF between 1988 and 1994 were reviewed. Nine patients had esophageal carcinoma and two patients bronchogenic carcinoma. A TEF was documented radiographically in all patients. Silicone stents were placed in all patients under endoscopic guidance. A chest radiograph was obtained for each patient immediately following stent placement to confirm proper positioning and to assess complications. A contrast study was performed within 24 hours after the procedure to evaluate the function of the stent and its efficacy for occluding the fistulous tract. The patients were followed until January 1995 or until their death (range 1.5-24. 0 months). RESULTS: Seven of the patients developed stent-related complications. Within the first 24 hours after stent insertion (which was successful in 100% of cases), 2 of the 11 patients developed minor complications. One patient had pooling of contrast around the proximal portion of the stent leading to aspiration of contrast, and one patient experienced transient, asymptomatic, idiopathic, esophagovenous intravasation. Delayed (>24 hours) complications related to stent placement occurred in five of the patients: one patient each had pooling at the proximal end of the stent with aspiration, worsening esophageal dysphagia causing reflux through the stent, caudad stent migration, superior stent migration, epithelial hyperplasia causing obstruction of the stent, and pressure necrosis. There were no cases of hemorrhage. Two patients were lost to long-term follow-up, and eight patients died of their disease, all unrelated to the stent placement. CONCLUSION: Silicone esophageal stents provide successful short-term palliation for most patients with malignant TEF but are not without associated complications. These complications, however, can usually be detected early using radiographic imaging, permitting remediation.

Enteroscopy in patients with gastrointestinal bleeding of obscure origin.

Approximately 5% of all patients with gastrointestinal hemorrhage will not have a bleeding site found after standard evaluation with upper endoscopy and colonoscopy. The source of bleeding in these patients is often the small intestine. In the past 2 decades, our ability to examine the small bowel endoscopically has been enhanced by the use of intraoperative enteroscopy and the development of push and sonde enteroscopes. In a stepwise evaluation of the patient with obscure gastrointestinal bleeding using enteroscopy, the identification of a bleeding source has been reported in 70-100% of patients, usually leading to palliative, if not definitive, therapy. In this review we discuss the indications, methods and yields of each of these procedures, and propose a diagnostic algorithm with which to approach these patients.

Optimal evaluation of patients with nonobstructive esophageal dysphagia. Manometry, scintigraphy, or videoesophagography?

The aims of this study were to compare diagnostic accuracy, cost, and patient tolerance of videoesophagography and esophageal transit scintigraphy to esophageal manometry in the evaluation of nonobstructive esophageal dysphagia. Eighty-nine consecutive patients underwent videoesophagography, scintigraphy, and manometry. The sensitivities for diagnosing specific esophageal motility disorders, using esophageal manometry as the standard, were 75% and 68% for videoesophagography and scintigraphy, respectively, with positive predictive accuracies of 96% and 95% for achalasia, 100% and 67% for diffuse esophageal spasm, 100% and 75% for scleroderma, 50% and 67% for isolated LES dysfunction, 57% and 48% for nonspecific esophageal motility disorders, and 70% and 68% for normal esophageal motility. The cost for videoesophagography is less than that for either manometry or scintigraphy. Both videoesophagography and scintigraphy were better tolerated than manometry. It is concluded that videoesophagography and scintigraphy accurately diagnose primary esophageal motility disorders, achalasia, scleroderma, and diffuse esophageal spasm, but are less accurate in distinguishing nonspecific esophageal motility disorders from normal. When considering accuracy, cost, and patient acceptance, these findings suggest that videoesophagography is a useful initial diagnostic study for the evaluation of nonobstructive esophageal dysphagia.

Heart transplantation is associated with an increased risk for pancreaticobiliary disease.

OBJECTIVE: To determine the risk factors for and the incidence, morbidity, mortality, and outcome of pancreaticobiliary disease in patients who have had orthotopic heart transplantation. DESIGN: Retrospective case-control analysis. SETTING: University hospital-based heart transplantation center. PATIENTS: 20 case-patients with pancreaticobiliary disease and 40 controls; all patients received heart transplants between 1985 and 1994. Controls were matched to case-patients by time of transplantation and length of survival. MEASUREMENTS: Charts were reviewed and data were extracted using a structured data abstraction protocol. Risk factors assessed before transplantation were cause of heart disease, history of diabetes, reproductive history, and sex. Risk factors assessed at presentation of pancreaticobiliary disease were weight change after transplantation, alcohol use, use of medications, recent total parenteral nutrition, age at symptom onset, recent rejection episode, cyclosporine level, complete blood count, time between transplantation and onset of symptoms, body mass index, calcium level, liver function test results before and at symptom onset, and lipid profile. RESULTS: Pancreaticobiliary disease occurred in 20 of 255 transplant recipients (7.8%). The incidence of disease in these patients within 1 year after transplantation was 3.9% compared with an expected rate of 0.2% per year (P < 0.01). A decreased serum calcium level was the only risk factor found to differ significantly between the two groups (mean +/- SD, 2.19 +/- 0.17 mmol/L in case-patients and 2.31 +/- 0.14 mmol/L in controls; P = 0.005). The duration of hospitalization for the treatment of pancreaticobiliary disease was longer for patients who received transplants than for patients who did not receive transplants and were treated at Temple University Hospital during a similar period (17.1 days compared with 7.2 days; P < 0.001). However, the outcome was excellent in most patients. CONCLUSIONS: Pancreaticobiliary disease occurs 17.4 times (95% CI, 9.2 to 32.7 times) more frequently in patients receiving transplants than in the general population. It is a seldom recognized but apparently common complication of orthotopic heart transplantation that results in substantial morbidity and health care resource use. Further study is needed to ascertain why this condition occurs and how the risk for developing it can be reduced.

A single intragastric pH electrode does not accurately measure intragastric acidity.

OBJECTIVES: Recent studies have raised concerns about the validity of using a single intragastric pH electrode to measure gastric acidity accurately and reproducibly. The aim of this study was to compare simultaneous intragastric pH measurements obtained from an indwelling glass pH electrode to those determined by aspirations from the gastric pool and from ex vivo measurement. METHODS: Twenty two normal volunteers were studied after fluoroscopically guided placement of a combined nasogastric tube-pH probe assembly. Simultaneous intragastric pH electrode and aspirate pH determinations were made basally for 120 min after administration of 15 ml of antacid (40 mEq buffering capacity) and for another 120 min an hour postprandially after administration of a second 15-ml dose of antacid. Gastric acid concentration (pH) measurements were recorded every 15 min during the following study protocols: 1) fasting baseline (30 min); 2) fasting antacid (120 min); 3) test meal (60 min); and 4) postprandial antacid (120 min). RESULTS: Intragastric pH was consistently and significantly lower as measured by intragastric pH electrode than by aspiration. Baseline hydrogen ion concentration ([H+]) was 4.3 times higher by direct electrode measurement than by aspirate. Antacid-administered fasting decreased [H+] maximally at 15 min to 48% and 82% of baseline by electrode and aspiration, respectively. The minimal residual intragastric [H+] after fasting antacid was 12.4 times higher by electrode than by aspiration. Postprandial antacid maximally reduced [H+] by 46% at 15 min when recorded using an electrode compared with 60% at 30 min by aspiration. Correlation coefficients for intragastric electrode [H+] versus aspiration [H+] were 0.26 (p = 0.253), 0.61 (p < 0.001), 0.56 (p < 0.01), and 0.31 (p < 0.001), for baseline, fasting antacid, meal, and postprandial antacid, respectively. CONCLUSIONS: Quantitative evaluations of intragastric acidity (pH) using an intragastric pH electrode and aspiration of gastric juice may yield remarkably different results. Studies that rely on a single intragastric electrode to quantitate intragastric acidity may be highly inaccurate.

Opioid and opioid-like drug effects on whole-gut transit measured by scintigraphy.

UNLABELLED: We studied the effects of several drugs on gastrointestinal transit (tramadol HCl, acetaminophen with codeine and placebo) in a randomized, double-blind, crossover study. METHODS: Combined gastric emptying, small bowel and colonic transit scintigraphy was performed in 12 normal subjects. Each subject received a standardized diet and study drug on Days 1-5. On Day three, subjects received a radiolabeled solid and liquid phase meal. RESULTS: No significant difference in the gastric T1/2 (mean +/- s.e.m.) of solids for placebo (69 +/- 7 min), APAP/C (74 +/- 15 min) or tramadol (686 +/- 8 min) (p = 0.86) were seen. Similarly there was no significant difference in the T1/2 of liquids for placebo (31 +/- 4 min), APAP/C (41 +/- 6 min) (p = 0.29). Orocecal transit times were not significantly different for placebo (237 +/- 20 min), APAP/C (311 +/- 26 min) or tramadol (311 +/- 10 min) (p = 0.12). Colon geometric centers (GC) for placebo at 24, 48 and 72 hr were 4.6 +/- 0.35, 6.0 +/- 0.28 and 6.8 +/- 0.08. The GC for tramadol and APAP/C were all significantly lower at 72 hr, 6.4 +/- 0.17 and 6.2 +/- 0.17, respectively compared to the placebo. The GC of tramadol at 24 and 48 hr (3.8 +/- 0.4, 5.4 +/- 0.26) were not significantly different from placebo. In contrast, the GC for APAP/C at 24 and 48 hr (3.3 +/- 0.31, 5.0 +/- 0.26) were significantly delayed. All subjects recorded a significant increase in constipation on drugs compared to placebo (p = 0.04). CONCLUSION: Tramadol and APAP/C had no effect on gastric emptying or small bowel transit. At equianalgesic doses, tramadol caused less delay in colonic transit than APAP/C for 48 hr and delay in the GC agreed with the subjective complaints of constipation on both drugs.

Endoscopic estimation of size: improved accuracy by directed teaching.

Previous studies have demonstrated the inaccuracy of endoscopic estimation of size. Although several devices have been developed to help improve estimation of size, none are convenient for clinical use. We have designed and evaluated a clinical teaching protocol to aid endoscopists in better estimating size. Thirteen "endoscopists" with varying levels of experience (none, less than 1 year, more than 1 year) estimated the size of six steel ball bearings placed into a model colon and viewed with a videoendoscope. They were then taught to compensate for optic distortion and retested immediately after teaching and again 1 month later. The mean error of estimation decreased from 28% before teaching to 8% after teaching (p < .05) and rose to 12% 1 month later (p < .05). Although the indices of mean error decreased immediately after teaching in all groups, only those individuals with less than 1 year of endoscopic experience retained the improvement 1 month after teaching. We conclude that endoscopists can be taught how to compensate for the optic distortion encountered during endoscopy. This teaching is most effective if performed early in the training program.

Whole-gut transit scintigraphy in the evaluation of small-bowel and colon transit disorders.

Scintigraphic methods for performing gastric emptying and colon transit studies are now well standardized. Although not as well established, several methods have been proposed for measuring small-bowel transit. The measurement of orocecal transit time appears to be a practical scintigraphic measurement of small-bowel transit. When combined into a single test of gastric emptying, small-bowel, and colon transit, whole-gut transit scintigraphy is an important, noninvasive tool for documenting dysmotility of any segment of the gastrointestinal tract. Despite attempts to simplify the study, whole-gut transit scintigraphy still requires a significant commitment of time and equipment. As with other gastrointestinal studies, each laboratory must determine which protocol best fits its clinical needs, equipment, and staffing. Attention must be paid to adhere to established protocols, or normal values will need to be determined for each laboratory. Despite these difficulties, whole-gut transit scintigraphy now represents an important clinical tool for the evaluation of patients with a wide range of abdominal complaints.